Department of Anesthesiology, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China; Department of Pain Medicine, Affiliated Hospital of Ningbo University, Ningbo, Zhejiang Province, China.
Postgraduate School of Zhejiang Chinese Medical University, Hangzhou City, Zhejiang Province, China; Department of Pain Medicine, Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang Province, China.
Pain Physician. 2024 May;27(4):E395-E406.
Glossopharyngeal neuralgia (GPN) is a condition that causes simultaneous headache and facial pain. The treatment for GPN is similar to the treatment for trigeminal neuralgia. Craniotomy microvascular decompression (MVD) or radiofrequency (RF) therapy is needed if conservative treatment with oral drugs fails. Therefore, the choice of radiofrequency therapy target is essential when treating GPN. However, finding the glossopharyngeal nerve simply by styloid process positioning is challenging.
Prospective, clinical research study.
Department of Anesthesiology and Pain Medical Center, Jiaxing, China.
To compare the clinical effects of computed tomography (CT)-guided RF treatments on GPN when the triple localization of cervical CT, the transverse process of the atlas, and the styloid process is used to those achieved when the treatments are guided by the styloid process alone.
From August 2016 to December 2019, 19 cases of GPN neuralgia were treated by radiofrequency under the guidance of CT guided by the styloid process only. (These patients comprised the single localization (SL) of styloid process group, in whom the target of the RF treatments was the posterior medial side of half of the styloid process). From January 2020 to December 2022, 16 cases of GPN were treated by RF under the guidance of CT with cervical CTA (CT angiography), the transverse process of the atlas, and the styloid process. (These patients were placed in the TL group, in whom the target of RF therapy was the gap between the internal carotid artery and the internal jugular vein behind the horizontal styloid process at the lower edge of the transverse process of the atlas). Two percent lidocaine was injected subcutaneously at the needle insertion site, and a stylet with a 21-gauge blunt RF needle (model: 240100, manufacturer: Englander Medical Technology Co., Ltd.) was slowly advanced toward the target. After that, an RF probe was introduced, then low (2 Hz)- and high (50 Hz)-frequency currents of the RF instrument (model: PMG-230, Canada Baylis company) were applied to stimulate. A successful test was defined as a 0.5-1.0 mA current stimulation that could induce the original pain area in the pharynx, the inner ear, or both, without any abnormal irritation of the vagus or accessory nerves. If the first test was unsuccessful, then in the SL group, the needle tip's position was adjusted to the distal end of the styloid process, and in the triple localization (TL) group, the needle tip depth's was fine-tuned. A continuous RF treatment was given after a successful test. The RF temperature was 95ºC for 180 seconds. The time that the first puncture reached the target, the puncture paths, the success rate of the first test, the time that the glossopharyngeal nerve was found, the frequency of adjustments to the position of the RF needle, the incidence of intraoperative and postoperative complications, and the therapeutic effects were recorded.
There were no significant differences in demographic data such as age, medical history, lateral classification, and pain score between the groups, but the TL group had a higher proportion of women than did the SL group. All patients' puncture targets were identified according to the designed puncture path before the operation. There was no difference between the 2 groups in the time of the first puncture to the target (5.05 ± 1.22 vs. 5.82 ± 1.51, P = 0.18), and the designed puncture depth (3.65 ± 0.39 vs. 4.04 ± 0.44). The difference in puncture angles (13.48 ± 3.56 vs. 17.84 ± 3.98, P < 0.01) was statistically significant, and in 8 cases in the SL group, the glossopharyngeal nerve could not be found after 60 minutes of testing, so the RF treatment was terminated. Meanwhile, this problem occurred in only 2 cases in the TL group. There were 3 cervical hematoma cases and 2 cases of transient hoarseness and cough in the SL group, whereas the TL group had, respectively, 0 and one cases of those issues. There was no death in either group.
More clinical data should be collected in future studies.
When using RF as a treatment for GPN, the glossopharyngeal nerve is easier to find by using the triple positioning of the cervical CTA, the transverse process of the atlas and the styloid process as the target to determine the anterior medial edge of the internal carotid artery behind the styloid process at the level of the lower edge of the atlas transverse process. The glossopharyngeal nerve is more difficult to locate when only the posterior medial edge of the styloid process is targeted. The single-time effective rate of 180 seconds of RF ablation at 90ºC for GPN can reach 87.5% (14/16), suggesting the treatment's potential for clinical application.
舌咽神经痛（GPN）是一种同时引起头痛和面部疼痛的病症。GPN 的治疗方法与治疗三叉神经痛相似。如果口服药物的保守治疗失败，则需要进行颅神经微血管减压术（MVD）或射频（RF）治疗。因此，在治疗 GPN 时，选择 RF 治疗靶点至关重要。然而，通过茎突定位找到舌咽神经具有挑战性。
前瞻性临床研究。
中国嘉兴市麻醉与疼痛医学中心。
比较 CT 引导下 RF 治疗 GPN 时，使用颈椎 CT、寰椎横突和茎突三重定位与仅使用茎突定位的临床效果。
2016 年 8 月至 2019 年 12 月，19 例 GPN 神经痛患者在 CT 引导下仅使用茎突进行射频治疗（这些患者为单一定位（SL）组，射频治疗的目标是茎突后内侧的一半）。从 2020 年 1 月至 2022 年 12 月，16 例 GPN 患者在 CT 引导下使用颈椎 CTA（CT 血管造影）、寰椎横突和茎突进行 RF 治疗（这些患者为三重定位（TL）组，射频治疗的目标是寰椎横突下缘水平下颈内动脉和颈内静脉之间的间隙）。在进针部位皮下注射 2%利多卡因，将带有 21 号钝射频针（型号：240100，制造商：英格兰医疗技术有限公司）的穿刺针缓慢推进至目标。然后引入射频探头，然后应用加拿大 Baylis 公司的 PMG-230 型射频仪器的低（2Hz）和高（50Hz）频电流刺激。成功测试定义为 0.5-1.0mA 的电流刺激可以在咽、内耳或两者之间诱发原疼痛区域，而不会对迷走神经或副神经产生任何异常刺激。如果第一次测试不成功，则在 SL 组中调整针尖位置至茎突末端，在 TL 组中微调针尖深度。成功测试后进行连续 RF 治疗。RF 温度为 95°C，持续 180 秒。记录首次穿刺到达目标的时间、穿刺路径、首次测试成功率、找到舌咽神经的时间、调整 RF 针位置的频率、术中及术后并发症的发生率以及治疗效果。
两组在年龄、病史、侧别和疼痛评分等人口统计学数据方面无显著差异，但 TL 组女性比例高于 SL 组。所有患者在术前均按设计的穿刺路径确定穿刺靶点。两组首次穿刺到达目标的时间（5.05±1.22 比 5.82±1.51，P=0.18）和设计穿刺深度（3.65±0.39 比 4.04±0.44）无差异。穿刺角度（13.48±3.56 比 17.84±3.98，P<0.01）的差异有统计学意义，在 SL 组中，有 8 例在 60 分钟测试后无法找到舌咽神经，因此终止 RF 治疗。而在 TL 组中仅发生 2 例。SL 组有 3 例颈椎血肿和 2 例暂时性声音嘶哑和咳嗽，而 TL 组分别有 0 例和 1 例发生这些问题。两组均无死亡病例。
未来的研究应收集更多的临床数据。
在使用 RF 治疗 GPN 时，通过颈椎 CTA、寰椎横突和茎突三重定位来确定寰椎横突下缘水平下颈内动脉和颈内静脉之间的内颈动脉前缘作为目标，比仅使用茎突后内侧缘作为目标更容易找到舌咽神经。当仅将目标定位在茎突后内侧缘时，找到舌咽神经更具挑战性。90°C 下 180 秒 RF 消融治疗 GPN 的单次有效率可达 87.5%（14/16），表明该治疗方法具有潜在的临床应用价值。
